Combined-modality therapy in the treatment of local-regional esophageal cancer

Multimodality therapy for cancers of the esophagus and gastric cardia

The role of multimodal treatment in the management of esophageal cancer is controversial. There are conflicting results from studies on the effect of neoadjuvant and/or adjuvant treatment on long-term survival. Following a search of the Medline database, the authors examine the results of randomized studies on the various treatment protocols available and discuss future therapeutic improvements.

Phase II studies on docetaxel alone every third week, or weekly in combination with gemcitabine in patients with primary locally advanced, metastatic, or recurrent esophageal cancer

BACKGROUND

The purpose of these studies was to compare efficacy and toxicity of docetaxel alone with the combination of gemcitabine and docetaxel for treatment of metastatic esophageal carcinoma.

PATIENTS AND METHODS

These studies enrolled patients with histopathologically verified squamous cell carcinoma or adenocarcinoma of the esophagus or cardia. Between March 1997 and June 1999, 52 patients were enrolled in the initial Phase II study (Study 1). They were scheduled for treatment with docetaxel 100 mg/m2 every third week as a 1-h infusion. The second Phase II study between September 2000 and March 2003 included 65 patients (Study II). They were given docetaxel 30 mg/m2, administered as a 30-min i.v. infusion weekly for four times, followed by 2 weeks of rest, and gemcitabine starting with a dose of 750 mg/m2 (if well-tolerated 1,000 mg/m2) on days 1 and 15, followed by 3 weeks of rest. A new cycle began on day 36. Patients were premedicated with betamethasone 8 mg p.o. on the evening before, and 8 mg i.v. 30-60 min before the docetaxel infusion. Response was confirmed by computed tomography and assessed at 12 and 24 weeks. Toxicity was assessed according to WHO scales.

RESULTS

In study I, 38 out of the 52 enrolled patients were valuable. Two patients experienced complete remission (CR) (5%), 10 patients partial remission (PR) (26%), nine patients stable disease (SD) (24%), and 17 patients showed progressive disease (PD) (45%). Toxicity mainly involved leukopenia, which in some cases required hospitalization and treatment with antibiotics. In Study II, 46 out of the 65 enrolled patients (70%) were assessable. Out of these, three patients (7%) had CR, eight patients (17%) had PR, 10 patients (22%) had SD, and 25 (54%) PD. Overall response was 24% while an additional 22% showed stable disease. Toxicity mainly consisted of leucopenia and pain.

CONCLUSION

Docetaxel as a single agent is active in esophageal cancer, both in treatment naive and in previously treated patients with recurrent disease. The overall response rate was 31%, with a good-safety profile. The addition of gemcitabine is well tolerated, but adds no efficacy. Weekly administration of docetaxel may be less effective. It demonstrates moderate efficacy and the doses used provide an acceptable safety profile.

Outpatient 5-fluorouracil, folinic acid and cisplatin in patients with advanced esophageal carcinoma

In a multicenter phase II study, 30 patients with unresectable, locally advanced or metastatic squamous cell or adenocarcinoma of the esophagus were treated with folinic acid 200 mg/m2/d, 5-FU 300 mg/m2/d, and cisplatin 20 mg/m2/d intravenously for 5 days every 4 weeks. Two of 13 patients with squamous cell carcinoma (SCC) had a complete response (CR), but one died of pneumonia after 9 months while still in CR, and the other still in CR after more than 5 years. Six other patients (3 SCC, 2 of 16 with adenocarcinoma, 1 mixed histology) had a partial response with a median duration of 9 months (range 5 to 57 + months) for an overall response rate of 27%. A further 6 patients (20%) had stable disease. Grade 4 neutropenia occurred in 6 patients (20%), with 5 requiring antibiotics for associated fever. Other grade 4 toxicities were nausea and vomiting (1), anemia (1), and thrombocytopenia (1); there were three early deaths (emphysema, cardiac arrest, pulmonary embolism). This combination appears to be an active, convenient regimen for advanced esophageal cancer, resulting in prolonged remission and survival in some patients.

Randomised phase II study of cisplatin and 5-fluorouracil (5-FU) versus cisplatin alone in advanced squamous cell oesophageal cancer

Patients with measurable or evaluable locally advanced or metastatic squamous cell carcinoma of the oesophagus were treated with cisplatin (CDDP), 100 mg/m2, combined with 5-fluorouracil (5-FU) at a dose of 1000 mg/m2 as a continuous infusion from days 1-5 (Arm A) or with CDDP alone (Arm B). Cycles were repeated every 3 weeks. 92 patients were randomised centrally, 88 were eligible. The response rate was 35% (95% CI (confidence interval), 20-54%) in Arm A and 19% (95% CI, 8-35%) in Arm B. One complete response was observed in each arm. The median duration of survival was 33 weeks and 28 weeks for Arm A and Arm B, respectively. Haematological and non-haematological toxicities were more frequent and more severe in Arm A. The most prominent toxicities were grade 4 aplasia and septicaemia (2), meningeal haemorrhage (1), cerebrovascular accident (3) and ischaemia of the lower limbs (1) all occurring in Arm A. Overall, seven treatment-related deaths (16%) were observed in Arm A, none in Arm B. The severe side-effects induced by the combination suggest that, currently, no standard chemotherapy can be recommended for patients with advanced squamous cell oesophageal cancer.

Pathologic assessment of tumor regression after preoperative chemoradiotherapy of esophageal carcinoma. Clinicopathologic correlations

BACKGROUND

The benefits of preoperative chemotherapy and radiation for esophageal carcinoma are under investigation. A pilot study was undertaken to determine if pathologic assessment of tumor regression correlated with disease free survival.

METHODS

Ninety-three resected specimens from patients treated with cis-dichloro-diamino cisplatin and irradiation before surgery were examined on semiserial sections. Patients selected for surgery were all Status 1 according to the World Health Organization (WHO) classification. Histologic typing was based on the WHO classification. Tumor regression grade (TRG) was quantitated in five grades: TRG 1 (complete regression) showed absence of residual cancer and fibrosis extending through the different layers of the esophageal wall; TRG 2 was characterized by the presence of rare residual cancer cells scattered through the fibrosis; TRG 3 was characterized by an increase in the number of residual cancer cells, but fibrosis still predominated; TRG 4 showed residual cancer outgrowing fibrosis; and TRG 5 was characterized by absence of regressive changes. Survival curves were estimated according to the Kaplan-Meier method. A quantification of the relationship between treatment failure and confounding variables (age, tumor location, tumor size, esophageal wall involvement by residual cancer and/or regressive changes, histology, treatment, adequacy of surgery, pathologic lymph node status, and tumor regression grade) was done using Cox's proportional hazards model.

RESULTS

Forty-two percent of specimens were TGR 1-2; 20%, TGR 3; and 33%, TGR 4-5. Univariate analysis found that tumor size, pathologic lymph node status, tumor regression grade, and esophageal wall involvement were highly correlated with disease free survival (P < 0.05). After multivariate analysis, only tumor regression (i.e., TRG 1-3 versus TRG 4-5) remained a significant (P < 0.001) predictor of disease free survival.

CONCLUSIONS

This study highlights the importance of tumor regression in the survival of patients with esophageal carcinoma treated with preoperative chemoradiotherapy. These findings suggest that tumor regression grade should be considered when evaluating therapeutic results.

Management of carcinomas of the upper gastrointestinal tract

Patients with oesophageal, gastric, and pancreatic carcinomas present a common and difficult problem for the clinician. Surgery is the best option for curative treatment but overall survival figures remain low. Recent improvements in our understanding of the biology of these tumours and improvements in their clinical staging, along with the development of combined modality approaches to local-regional disease, have led to renewed optimism that survival figures may be improved. This is particularly so for oesophageal and gastric carcinomas. In addition, there have been advances in the palliative management of all three tumours. This article examines some of these developments and looks at future prospects.

Preoperative high-dose radiation and chemotherapy in adenocarcinoma of the esophagus and esophagogastric junction

BACKGROUND

Esophageal adenocarcinoma (EA) incidence is rising. Defining optimal management is essential because median survival after surgery alone is only approximately 12 months. High-dose radiation (> 5000 cGy) and chemotherapy (HDRCT) preoperatively for patients with EA has not been fully investigated. We evaluated tumor response, resectability, and survival following HDRCT in patients with localized EA.

METHODS

Thirty patients with American Joint Committee on Cancer (AJCC) clinical stage I or II EA were prospectively treated with HDRCT. The treatment consisted of 60 Gy radiation at 2 Gy per fraction with concurrent infusional 5-fluorouracil (5-FU) and a bolus of mitomycin C followed by esophagogastrectomy. The range of follow-up was 7 to 69 months, with a median of 31 months.

RESULTS

Twenty of 30 patients (67%) received full-course HDRCT. Severe esophagitis precluded full-dose radiation in 10 patients. Three patients developed neutropenia and fever requiring admission to a hospital. Two patients died preoperatively of treatment-related complications. Nine patients were not explored. Eighteen patients were resected with curative intent; the remaining three had metastatic disease at laparotomy. Seven of 18 resected patients (39%), or 7/30 (23%) of all patients treated, had a pathologic complete response. There was one operative death. Overall local control was seen in 25/30 patients (83%). Median overall survivals for resected and for all patients were 23 and 13 months, respectively.

CONCLUSIONS

Preoperative HDRCT in patients with EA results in encouraging local tumor response and local control. Overall survival, however, may not be improved, and the treatment-related mortality of 10% is higher than reported with surgery alone or with preoperative chemotherapy.